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# The Mediaeval concept of Medicine

#### by Mark D F Shirley

The copyright of this article remains with the original author. Articles may be copied or distributed freely for personal non-profit use, provided that the author is properly credited.

The two auctores of Medicine according to Ars Magica 4th Edition are Galen and Hippocrates. Galen (131 - 201 AD) lived after Hippocrates (460-370 BC), and commented extensively on his work, whilst writing his own texts at a prodigious rate. Galen is considered the founder of humoral theory, expounding on the theories of Hippocrates and other philosophers, and it is this that guides mediaeval medicine.

### The origins of pharmacy

In the autumn of Roman imperial power and culture, scholars began recording all the medical knowledge acquired over centuries of study and conquest. The famous book De Materia Medica by the military doctor Dioscorides, describing more than six hundred vegetable, animal and mineral remedies, laid the basis for pharmacology. Dioscorides also produced a discourse on poisons and antidotes. A little earlier, the physician Cornelius Celsus had completed a huge encyclopaedia of Greek and Alexandrian medicine.

However, it was not until the second century of the Christian era that the tone was really set by Galen (Claudius Galenus in Latin, Klaudios Galenos in Greek), who was born on 22 September 131 AD in Pergamum, Asia Minor, and died in Rome in 201 AD.

This Graeco-Roman doctor, pharmacist and philosopher produced around five hundred books and treatises and was unquestionably the leading scientist of his day. Galen wrote on all aspects of medical science, his books on medicine and anatomy shaping medical thinking throughout the Middle Ages and beyond. The word "galenic" is still used to describe drugs and medicaments made directly from vegetable or animal ingredients (known as "simplicia") using prescribed methods.

### The gladiators' doctor

After initially studying philosophy, particularly Aristotle, Galen began to specialise in medicine at the age of seventeen. Having gained experience on travels through Greece, Asia Minor and Palestine, when he further developed his skills, Galen established himself as a doctor in Alexandria (Egypt), the leading medical centre of the day.

In about 159, at the age of 28, Galen returned to Pergamum, the city of his birth, where he was appointed doctor to the gymnasium attached to the local sanctuary of Asklepios. (In the Greek pantheon, Asklepios was son to the sun god Apollo, traditionally depicted carrying a staff with a serpent coiled around it.) Five years later, however, Galen moved to the capital of the Empire to teach medicine. He quickly gained great fame and was made personal physician to Emperor Marcus Aurelius and his son Commodus. He also had the job of looking after the gladiators; by treating their wounds, Galen was able to expand his anatomical knowledge still further. Now he was also able to carry out surgery and study plastic anatomy.

### The galenic pharmacy

Galen also helped to shape pharmacological science. In addition to running a thriving medical practice, he had his own pharmacy which stocked hundreds of medicines made from vegetable and animal ingredients. Galen catalogued countless remedies, recording how each was made. One striking feature of his work was the attention he paid to the precise quantities of the various ingredients used in the preparation of each remedy, and to the doses which had to be given. He believed that, depending on the dose taken, every medicine was capable of having a slight, strong, harmful or even fatal effect on the patient.

### Humoral pathology

Galen firmly believed in what is known as humoral pathology: the science of the bodily fluids pioneered by the Greek physician Hippocrates (460 to 377 BC). Humoral pathology is based on the notion that the human body contains four humours or bodily fluids (blood, phlegm, choler and melancholy) and that good health depends upon these humours being kept in balance. Hippocratic theory suggested that if any one humour became predominant, ill health would result; however, Galen argued that sickness could also be caused by an insufficiency of one of the four humours. This belief was the guiding principle of Galenic medicine.

### Physiology & Anatomy

The development of human physiological science owes much to Galen's theories and discoveries. For the ancients, the functions of the heart and blood vessels were a great mystery. Five hundred years before Christ, the Greek Alcmaeon of Croton suggested that sleep was caused by blood draining from the brain via the veins, and that death was the result of the brain becoming completely drained. Two hundred years later, Aristotle ascribed the power of thought to the heart, which he contended also contained the soul. Erasistratus argued that intaken breath entered the arteries, which thus carried nothing but air. Galen demonstrated the error of many of these theories.

For example, as mentioned above, Aristotle had held that the heart was the seat of the sensitive soul and the source of nervous action, while the brain was of secondary importance, being the coldest part of the body, devoid of blood and having for its chief or only function to cool the heart. Galen attacked this theory by showing experimentally that all the nerves originated in the brain, either directly or by means of the spinal cord. He found that sensation and movement were stopped and even the voice and breathing were affected by injuries to the brain, and that an injury to one side of the brain affected the opposite side of the body. He also proved that the arteries contained blood and not air or spiritus as had been generally supposed. He did, however, subscribe to the contemporary theory that blood flowed back and forth within the arteries. It was not until 1628 that the Englishman William Harvey showed that the blood circulated round a closed system. Galen failed to perform any experiments with the pulmonary veins, and so the notion persisted that these conveyed "spirit" and not blood from the lungs to the heart.

His knowledge of anatomy from the dissection of animals made him a superlative surgeon, and he hardly lost a life, even, as in one case, where the human heart was laid bare by injury. He was very much of the opinion that in the structure of any animal we have the mark of a wise workman or demiurge, and of a celestial mind - in short, that design indicates the existence of God.

### Philosophy

On the basis of his philosophical studies, Galen came to the conclusion that the various bodily functions were induced by the pneuma or universal spirit. He believed the pneuma to be a fine, spirit-like material which drifted through the universe and which controlled and organised physical bodies. Galen distinguished between three types of spirit: the spiritus vitalis or life spirit, originating in the heart and flowing through the arteries; the spiritus animalis or animal spirit to be found in the brain and nerves; and the spiritus naturalis, or natural spirit, formed in the liver.

However, Galen also believed that the life process was sustained by food, which was convened into blood in the liver. Blood from the liver nourished the heart, lungs and other organs, including the brain. Waste materials were also thought to be removed by the blood. Thus, blood circulation and metabolism are critical elements of galenic physiological theory, and Galen was the first person to suggest a relationship between food, blood and air.

Interestingly, later medical and church authorities considered Galen's work to be based upon divine inspiration and therefore infallible, dubbing him Divinus Galenus (Galen the Divine). Those who dared call Galen's theories into question often ended their lives burnt at the stake.

### Diagnosis

Galen's detractors claimed that his skill in medicine was a result of divination, were it was actually the product of careful observation and experience. In fact, Galen was highly critical of the use of magic in medicine, though many of the medicines he describes in his lists of simples seem somewhat magical to the modern reader. The difference between Galen's practice and that of his contemporaries that he is so scornful of is the absence of incantations and amulets.

One of the most studied of Galen's works in mediaeval times was The Healing Arts ( ), in which Galen lists he diagnostic features of hot or cold internal organs, devoting many chapters to the signs of a hot and dry hear, signs of a hot liver and signs of a cold lung. For example, among the signs of a cold brain are excessive excrements from the head, stiff, straight red hair, a late birth, malnutrition, susceptibility to injury from cold causes and to catarrh, and somnolence. Identification of this imbalance allow the correct treatment of disease.

### Remedy

Galen's medicinal simples (lists of animal and plant ingredients with medicinal properties) include the bile of bulls, hyaenas, cocks, partridges and other animals. A digestive oil can be manufactured by cooking foxes and hyaenas, some alive and some dead, whole in oil. Galen discusses with perfect seriousness the relative strengths of various animal fats, those of goose, hen, hyaena, goat, pig and so forth. He decided that lion's fat is by far the most potent, with that of the pard next. Among his simples are also found the slough of a snake, a sheepskin, the lichens of horses, a spider's web and burnt young swallows. Among his prescriptions for toothache he recommends holding for some time in the mouth a frog boiled in water and vinegar, or a dog's tooth, burnt, pulverised and boiled in vinegar. Cavities may be filled with toasted earthworms or spider's eggs. Teething infants are benefited if their gums are moistened with dog's milk or hare's brains, and for colic he recommends dried cicadas with three, five or seven grains of pepper. Despite this, he is sceptical of the use of millipedes boiled in oil as a cure for earache. In all things Galen tries to find some satisfactory explanation of the strange properties which he believes exist in so many things. Galen's teacher Pelops, for example, explained why the ashes of river crabs are used for the bite of a mad dog. The crab is efficacious against hydrophobia because it is an aquatic animal. River crabs are better for this purpose than salt water crabs because salt dries up moisture. For many remedies Galen merely cites that the best explanation of all such action is that it is the peculiar property or occult virtue of the substance as a whole.

It is not uncommon for Galen's prescriptions to contain as many as 25 ingredients. Galen argues that if all diseases could be cured by simples, no one would use compounds, but these are essential for some diseases, especially such as require the simultaneous application of contrary virtues. Also when a simple is too weak or strong, it can be toned up or down to just the right strength in a compound. Procedure as well as substances suggestive of magic is found to some extent in Galen's works. He instructs, for example, to pluck a herb with the left hand before sunrise. He also condones hanging certain herbs around the patient's neck (known as ligatures) - such as the use of peony to cure epilepsy. He suggests that perhaps some particles from the root can be drawn into the patient's breathing or altered the surrounding air. He draws the line at the use of images, characters and incantations, which he declares as either magical or superfluous.

He notes that children occasionally resemble their grandparents rather than their parents. He disputes the assertion of Epicurus that there is no benefit to health in Aphrodite, and contends that at certain intervals and in certain individuals and circumstances, sexual intercourse is beneficial. His discussion of anodynes and stupor or sleep-producing medicines shows that the ancients had anaesthetics of a sort. He recognised the importance of breathing plenty of fresh, invigorating, and unpolluted air, free of any intermixture of impurity from mines, pits or ovens, or of putridity from decaying vegetable or animal matter, or of noxious vapours from stagnant water, swamps and rivers. As was usual in ancient and mediaeval times, he attributes plagues to the corruption of the air, which poisons men breathing it.

### Humoral Theory and Medieval Medicine

Galen held as his fundamental theory of nature the view that all natural objects upon the globe are composed of four elements, earth, air, fire and water, and the cognate view, which he says Hippocrates first introduced and Aristotle later demonstrated, that all natural objects are characterised by four qualities, hot, cold, dry and moist. From the combinations of these for are produced various secondary qualities. Neither hypothesis was as yet universally accepted n Galen's day, and Galen felt it incumbent upon him to argue against those who contended that the human body and the world of nature were made from but one element. Galen explains that philosophers do not consider any particular variety of earth or any other mineral substance as representing the pure element earth, which in the philosophical sense is an extremely cold and dry substance to which adamant and rocks make perhaps the closest approach, but the earths that we see are all compound bodies.

The basic premise of humoral theory was that a person's health was dependent upon keeping a balance of the humours of the body. These humours, which were first discussed by the Greeks, were a direct reflection of the view that the world was made of four elements. Thus people consisted of some combination of the elements, and their health was dependent on the combination. Each person had their own personal humoral make up, however there were natural events that would affect the balance of these humours. A proper mixture of the four humours was called eucrasia, whereas, unduly misproportioned cause disease, named dyscrasia.

The four humours were blood, black bile (or melancholer), yellow bile (or choler) and phlegm. Blood was hot and moist, generated in the heart, and related to the element of water. Black bile was a product of the spleen, and was cold and dry, thus the earthy component of the body. Yellow bile was hot and dry, and created in the liver, it corresponded to the element of fire. Finally, phlegm was cold and moist, created in the brain, and was most closely related to the element of air.

The various humours were associated with the time of the year, the astrological cycles, and the astrological information pertaining to a person's birth. These changes in nature's cycles would cause subtle changes in a person's basic balance of humours, perhaps making them more susceptible to humoral imbalances. Thus doctors also had to be well versed in astrology, besides their medical training to treat their patients correctly.

The Hippocratic treatises often associate disease with some imbalance in the body or interference with its natural state. In several of these treatises, disease is associated with the bodily humours. One version of this is worked out in On the Nature of Man, where it is argued that the four humours are the basic constituents of the body and that imbalances among these humours are responsible for disease:

"The human body contains blood, phlegm, yellow bile and black bile. These are the things that make up its constitution and cause its pains and health. Health is primarily that state in which these constituent substances are in the correct proportion to each other, both in strength and quantity, and are well mixed. Pain occurs when one of the substances presents either a deficiency or an excess, or is separated in the body and not mixed with the others."

Hippocrates attested that the common elements of all existing things are hot and cold, dry and moist. Galen's dissections had revealed to him that there were common elements of all living things as well - arteries, veins, sinews, ligaments, membranes, flesh, etc. So if the four qualities were the primary parts of all objects that exist, and these 'uniformly composed materials' were the primary parts of all animals (or "creatures with blood", to use his terminology), then the four humours must be the intermediate between the two.

He used the analogy of milk to explain how all creatures with blood can be formed from opposing qualities. When milk curdles, it turns into a watery whey and solid curds. However, when it is milk, it is intermediate between the two. Like milk, blood has a kind of ichor analogous to the whey, and a kind of slime analogous to the curds. One can see fibres in the blood, and if these are removed, the blood will not thicken and coagulate. When a creature forms out of the blood of its mother's womb, the soft, hot parts of the blood separate out to form the flesh, the hard cold parts become sinew, etc. The womb draws the blood and fashions the embryo from it, drawing the thicker parts out of it to form the harder parts of the body, and uses the wetter material to make the soft parts of the body.

The effects of unbalanced humours could show themselves in many ways. A person's complexion, or outward appearance, could change. Perhaps their personality would be modified. One of the major signs, though, was what they saw in their dreams. The medical views of the day would state that if you have fear without cause, apprehension, uneasiness of mind, you probably have an overabundance of melancholy in the blood. In a similar way, if you dream of fire, and red and yellow things you probably have too much choler in your system.

### Therapy and Treatment

If disease is associated with imbalance, then therapy must be directed toward the restoration of balance. Diet and exercise (which together make up what were called "regimen") were among the most common therapies. Purging the body - through blood-letting, emetics, laxatives, diuretics and enemas - was another way or redressing an imbalance of bodily fluids. Careful attention to seasonal and climatic factors, and to the natural disposition of the patient, was also part of successful therapy. And through it all, the physician was to keep in mind that nature has its own healing power and that the physician's most basic task is to assist the natural healing process. A considerable part of the physician's responsibility was preventive - the giving of advice on how to regulate diet, exercise, bathing, sexual activity and other factors that would contribute to the patient's health.

Hippocratic medical therapy was mostly symptomatic, that is, to wait until the disease presented signs and symptoms and treat each of these to alter its course as indicated in each individual case.

Galen proposed that a dry medicine was good for a moist disease, and that in a compound medicine, by mixing a very cold with a slightly cold drug in varying proportions a medicine of any desired degree of coldness might be obtained. In general he regarded solids like stones and metals as dry and cold, while he thought hat hot and moist objects tended to evaporate rapidly into air. So he declared that dryness of solid bodies was incurable, and he believed that children's bodies were more easily dissolved than adults' because they are moister and warmer. So, to restore the patient's physiological balance, doctors needed to bleed their patients or to prescribe laxative, emetic or sudorific medication.

Herbs and herbals were important to medicine in the Middle Ages. Since most medical theory believed that maladies were caused by unbalanced humours, the use of diet, and thus herbs, to control these conditions was very common. Herbs fell into two broad categories, purgatives and laxatives, used on the hot humours (blood and bile), and digestives, used on the cold humours (melancholy and choler). As diseases were caused by the overabundance of a humour, herbs were used to purge the system, or to absorb excess humours. Most medieval doctors would have been able to trace a sickness to a specific imbalance of the humours that he then would treat with a regiment of either purging the over-abundant humours, or perhaps changing a person's diet to increase a certain humour.

In the Canterbury Tales by Geoffrey Chaucer (1343-1400), the Nun's Priest's Tale relates the use of herbs to rebalance the humours. Pertelote recommends a strong dose of herbs to purge Chaunticleer both upwards and downwards. She also recommends digestives of worms to help clean out his system. She is proposing radical treatment to try and cure him quickly. The herbs she recommends are:

Middle English Name | English name | Properties
lawriol | spurge-laurel | Induces Vomiting
centaure | centuary | Expels bilious and heavy humours through the bowels
fumetere | fumitory | Induces bilious urine
elles of ellebor | hellbore | Purges lower tracts of phlegm and choleric humours
katapuece | euphorbium | Continuous irritant that dissipates lots of humours
gaitrys beryis | buckthorn | Repels evil influences of magicians
erbe yve | ivy | Effective on nervousness

### Human temperaments

Drawing upon Hippocrates' theory regarding the four humours, Galen suggested the existence of four basic human temperaments, each of which was caused by a predominance of one of the four humours. First, there was the sanguinicus, whose cheerful and lively temperament resulted from the dominance of the blood. They were characteristically amorous, happy and generous. The temperament of the calm and tough phlegmaticus was influenced by excess phlegm. They tended to be dull, pale and cowardly. The worry and gloominess of the melancholicus were due to a surfeit of melancholy, and they were gluttonous, lazy and sentimental. Finally, the energetic cholericus had too much choler in his or her system, and tended towards violence and vengeance. Thus Galen believed that one's personality was closely related to one's physical make-up.

The following table gives a quick guide to the correspondences of the various humours. These were important in therapy: it was well known that a different humour was dominant at different times of the year. Phlegm, for example, which is cold, increases in quantity during the winter; and therefore during the winter phlegmatic ailments are particularly common. Blood predominates in the spring, yellow bile in the summer, and black bile in the autumn. Diet could be regulated using these correspondences - those with an excess of sanguine humour should avoid sweet foods and concentrate on more acid foods to reduce the dominance of blood. Herbs with a bitter taste are most likely to promote yellow bile, etc.

Humour | Other names | Properties | Body Part | Absorption Point | Corresponding Element | Season | Age
blood | - | hot moist sweet | heart liver | nostrils | water | spring | childhood (Age 1 to 14)
yellow bile | red bile choler | hot dry bitter | liver | ears | fire | summer | youth (Age 14 to 28)
black bile | melancholer | cold dry acid | spleen | eyes | earth | autumn | manhood (Age 29 to 48)
phlegm | - | cold moist salt | head bladder | bone | air | winter | old man (Age 48 to 70)

Some of Galen's commentaries on Hippocrates' work can be found here. Of particular interest is his commentary of On the Elements as this deals with humoral theory.